••ALERTS: Screening Bands, Staff Effectiveness Suspension, 2008 Top 10, Fld Rvw:Com/Cult, Fld Rvw:Staffing, ••REFS: Violence Tracer, HAI Compendium,Fire Watch, ILSM Compliance, ••DWNLDS: Pt Satisfaction MP3, ••PSQ: 6-Month Preliminary Analysis
.
THE JOINT COMMISSION (TJC and JCR)
.
[Index] [Blog] Perspectives (July, Vol 29 #7)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- The 2009 Accreditation Decision Process: A Closer Look at Central Office Reviews [ALERT: JCSC] Last December, TJC announced that the number of direct-impact RFIs would no longer serve as an automatic trigger for CA or PDA. Instead the numbers depending on the size and complexity of your hospital (aka 'band;) would trigger a central office screening (i.e., a more in-depth evaluation of your survey results) for possible CA or PDA. This update only describes 2 possible outcomes of that screening (vs. 3 outcomes in December article and it fails to include the earlier chart indicating the triggering number of direct-impact RFIs. However, it does provide useful examples of Central Office Survey Report Review Objectives that LDR and JCSC should review. See our 2008 Dec RT review by Glenn D. Krasker, MHSA for more details.
Pg03- Top 10 Standards Compliance Issues for 2008 [•• REF••] The top 10 are provided on tear-out cards in the hard copy edition of Perspectives. JCSC and those expecting survey soon should be aware that the 10 include EC.5.20 (45%), IM.6.50 (43%), MM.2.20 (37%), NPSG 2C (37%), IM.6.10 (31%), EC.5.40 (26%), NPSG 3D (25%), HR.1.20 (22%), UP 1C (21%) and NPSG 8A (19%).
Pg05- Accreditation Manual Updates Mailed in June FYI: JCSC. You should have received your 2009 manual Update 1, but if you do not have it by 7/15/09, contact your account representative (630.792.307).
Pg05- Field Review for Proposed Hospital Requirements: Advancing Effective Communication, Cultural Competence, and Patient-Centered Care FYI: JCSC, HR. This issue was reviewed in our June RT. See also 'Cal: 6/22 under SHCC Additions below.
Pg07- Maintaining Vigilance for Pandemics FYI: IC. Joint Commission Resources has created a pandemic preparedness page for Swine Influenza A (H1N1) on its Web site with free articles, resources and links to helpful products to include the following:
• CDC Guidelines
• JCR's Pandemic Point-of-Care Pocket Guide
• Free tool to track pan flu supply
• Free Monograph Offers Seasonal Influenza Vaccination Strategies
Pg09- Field Review for Proposed Staffing Effectiveness Requirements: Interim Step for Hospitals and Long Term Care FYI: JCSC, RN. This issue was reviewed in our June RT. See also See 'Cal: 6/20 under SHCC Additions below.
Pg10- Updates to Quality Check FYI: JCSC. Effective
Pg10- What's Next with S3: New Enhancement Adds Patient Perspective of Care to Mix FYI: PtAd, PI. The July 2009 quarterly update will include Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data (April 2007 through March 2008) . Developed by CMS and AHQR, this tool is reportedly the first publicly available and standardized survey for gathering feedback from inpatients about their hospital care and services (i.e.,, patient satisfaction) at both a state and national level. 10 of the 18 HCAHPS questions (listed in the article) on critical aspects of a patients’ hospital experience will be incorporated into S3 and PHP. Although currently, HCAHPS is only for adults and specialty hospitals, (such as psychiatric hospitals) are not included in the HCAHPS survey those responsible for patient satisfaction measurement (PtAd, PI, LDR) might find it useful technology to be aware of and to borrow from.
[Index] [Blog] The Source (July Vol 7 #7)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- Preparing Information Surveyors Will Need: Is your organization prepared for an on-site survey? FYI: JCSC. There is nothing new in this very basic review of survey prep for JCSC. Still the fundamental need to review 1 - The Survey Activity Guide, 2 - Survey Agenda and 3 - your PFA's might make this a simple but useful review for first timers and those just gearing up for survey. In addition, a documentation readiness chart is provided that can be photocopied for multiple uses.
Pg03- Edition for Beginners: This Month's Tip: E-mailing a Standard FYI: JCSC. This article provides 9 step-by-step instructions on how to e-mail a standard to themselves or other staff using the electronic accreditation manuals.
Pg06- Tracer Methodology 101: The Violence Tracer [•• REF••] Although the Violence Tracer is a program-specific tracer for behavioral health care programs, it (or a variant thereof) can be triggered in any setting. JCSC and LDR would be wise to incorporate this tracer into your survey preparations (e.g., practice tracers) and use it as a PI tool to help assess and improve the management of violence and reduction of such risks. Review the sample questions and tips provided in this article.
Pg08- Spotlight on Success: Leadership Initiatives Produce Positive Outcomes FYI: LD. Evolving a culture of quality and safety does not happen over night nor is it likely to result from any single action. In that context LDR might find it useful to peruse this article for a few ideas on more staff involvement in ongoing standards compliance that might help nudge your organization further along the direction you would like it to go.
[Index] [Blog] Patient Safety (July Vol 9 #7)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg01- Protecting the Patient: The Joint Commission Collaborates on Developing Infection Prevention and Control Compendium: [••REF••] Four major healthcare organizations (SHEA, IDSA, AHA, APIC) have joined with TJC to produce the A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals that organizes all the evidence- based strategies that have been found to prevent those HAIs causing the greatest mortality (including MRSA and CDI) into practical guideline that can serve as a one-stop prevention resource. Strategies are organized into 4 categories. Basic practices and Special approaches for certain high-risk populations have good or moderate evidence to support their use (i.e., A or B-level recommendation). Level C recommendations are categorized as 'Unresolved issues'. There is a final category of approaches that should not be implemented. The guideline also includes performance measures and patient guides (http://www.preventinghais.com/) for each HAI. IC and related PPR should not only review relevant sections of the compendium, but strongly consider performing a gap analysis between your current approaches and their A or B-level recommendations to better ensure compliance with NPSG.07.03.01, NPSG.07.04.01 and NPSG.07.05.01 that TJC says were directly influenced by the compendium.
[Index] [Blog] Environment of Care News (July Vol 12 #7)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Pg05- Conducting the Fire Watch of Standard LS.01.02.01 [••REF••] SFT, EOC. This is the same article first published in June Perspectives. See review in our June RT.
Pg06- Mitigating Life Safety Deficiencies with ILSM: Examining the "Life Safety" (LS) Chapter, Part 3 [••REF••] This is the 3rd in a series of articles on the new LS chapter. It is an excellent review of ILSM compliance requirements for SFT, E&M, LDR, EOC and JCSC. The first thing to be noted is that the implementation of ILSM measures are not just for periods of construction, but 'any time there is a Life Safety Code deficiency that cannot be immediately addressed'. The article also places emphasis on the requirement for an ILSM policy (LS.01.02.01, EP#3). The author sees all the subsequent EP's being dependent on having a comprehensive, written, and regularly reviewed ILSM policy. There is also a brief overview of the 11 ILSM activity options to be considered in that plan. Note: Parts 1 and 2 were presented in the Feb and May issues of EC News and also reviewed in our Feb and May RT newsletters.
Pg08- Health Care-Associated Illnesses and Record-keeping: Using the OSHA Log 300: The OSH Act permits and approves state plans to cover public sector employees. The GB should ensure that the plan provides protection equivalent to that provided by the Federal OSHA regulations. The circumstances would be different for psychiatric facilities not in the public sector. SIG says under standard LD.04.01.01 the requirement for hospitals to comply with law and regulation also applies to federal (OSHA) requirements related to the recording and reporting of work-related employee illness and injury. HR should note that for OSHA, it is not the activity being performed, but rather the location that determines whether or not the illness/injury is work-related. The article reviews the use of the OSHA log 300, form 301 (relevant for state hospitals if required by your state plan), the importance of accurate recording and, in a few cases, of reporting work-related illness/injury. OSHA actually provides a detailed injury and illness record-keeping Web site (http://www.osha.gov/recordkeeping) with links to The OSHA Recordkeeping Handbook, training presentations, applicable Federal Register notices, Frequently Asked Questions and OSHA’s record-keeping related Letters of Interpretation. See also SL6: 09sig_Is the use of OSHA Log 300/Form 301 required by TJC?
Joint Commission This Month For State Hospital Associations (TMFSH)
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
TMFSH June
- Survey of staffing effectiveness standards suspended; interim EPs being field reviewed: [ALERT: JCSC, HR, PT] Effective immediately, survey of the Staffing Effectiveness standards (PI.04.01.01 for hospitals and HR.1.30 for long term care organizations) has been suspended. Two interim elements of performance, EPs 12 and 13 at PI.02.01.01 (PI.2.10 for Long Term Care) are being field reviewed until 7/22/09. See Field Review: Staffing Effectiveness in our June RT.
- Accreditation report changes stemming from hospital deeming application: FYI JCSC. Beginning in July, hospital accreditation reports will include any Medicare standard-level or condition-level deficiencies found during the survey. Detailed definitions of standard-level or condition-level deficiencies are provided in the article.
- TMFSH Becomes Weekly Newsletter: Beginning with the July issue, This Month for State Hospital Associations and Joint Commission Online will be combined and become a weekly electronic newsletter. As such, we will no longer review it in a stand-alone section, but rather include its relevant updates in our 'Internet Highlights' section below.
TMFSH July (Review Pending TJC Release)
.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
.
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
INTERNET HIGHLIGHTS
RTP Jump **Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
Joint Commission Resources (TJC)
- Free online Antibiotic Resistance Toolkit from JCR- Field Review: FYI: IC, LDR A free, downloadable Toolkit (What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance) is available to help hospitals reduce MDROs.
- Free “Test drive” of distance education offerings acknowledged: The free offering are:
- Free Web-based education course {Info}
- Free audio conference for accreditation managers: Driving & Sustaining Patient Satisfaction (MP3 x 70 min) FYI: JCSC, PtAd, LDR
SHCC Additions (Note: The SL1 library is in the process of being converting to 2009 Standards/terminology)
2009 Member Surveys (SL5)
If you anticipate a survey soon, please click here
SHCC has determined that in the first six months of 2009, eleven of our state hospital members experienced full unannounced Joint Commission surveys (see below). A preliminary analysis of 2009 survey dates in comparison to the previous full survey revealed the following:
- Average time since last survey: 1053.8days or approximately 35.1 months
- Percent of 10 hospitals having 2009 surveys earlier than 36 months: 72.7%
Members who have not submitted PSQ feedback are implored to do so as soon as possible.
This year is off to a challenging start. We really need your 2009 feedback! Go to www.shccPSQ.com or send us a copy of your survey report and surveyor photos/feedback.
Reviews by Sara Virginia Knight, RN, PhD and Richard Fields, MD
RTP Jump**Top** TJC**Perspectives**Source**Pt Safety**EC News**This Month**CMS**Internet**Surveys**New Adds**Abbreviations**Bottom
ALL: Everybody, CHP: Chaplain, C&P: Credentialing & Privileging, E&M: Engineering & Maint, EOC: Environment of Care, FB: Finance/Business, FdDt: Food services/Dietary, GB: Gov Body, HR: Human Resources/Personnel, HST: Human Service Tech/Aid, IC: Infection Control, IM: Info Mgt/Med Records, IT: Info Technology, JCSC: Jt Com Survey Coordinator, LDR: Leadership/Mgt, MEC: Med Exec Committee, MD: Medical Staff, ofco: Officer and/or Committee, PI:Performance/Quality Improvement com/dept, PPR: PPR team mbrs/ldrs, P&T: Phrm & Therapeutics Com, Phrm: Pharmacy,PSY: Psychology, PtAd: Patient Advocate, PtEd: Patient Education, RHB: Rehab/Activity Therapy, RN: Nursing, SFT: Safety,StEd: staff ed & training dept, SW: Social Work, TxTm: Treatment Team, UrUm: Utilization Review/Management, X: Exec, Dir or Chief (e.g., MDx = Medical Director)
